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How can prevention become a part of everything we do?
We all welcomed the emphasis on prevention in the NHS Five Year Forward View launched by Simon Stevens earlier this month.
Disease prevention, the role of employers in promoting employee health and the recognition of the increasing significance of obesity to future health are all now priorities for the NHS.
This Chief Nursing Officer’s Conference gives us an opportunity to reflect, in the company of some of the most influential nurses in the country, on what that actually means for the clinical leaders who will need to inspire and motivate staff to deliver on prevention – while also meeting winter pressures and other priorities.
First we can be clear on how these priorities apparently opposing priorities actually support each other. For a start there is the sheer cost of behaviour-related illness: NICE estimates that physical inactivity costs the NHS £1067 million every year, smoking £2872 million, alcohol misuse £3614 million and overweight £6048 million. That’s a lot of money that could be freed up to support safer staffing and other pressing demands on NHS resources. And we are facing a demographic of an ageing population which will lead to a big increase in behaviour related chronic ill-health – more of us living longer with the consequences of our unhealthy choices.
Health-related behaviour, particularly relating to tobacco, diet, physical inactivity and harmful alcohol consumption, account for a significant and growing proportion of premature deaths and chronic illness. For example, the World Health Organisation estimates that at least 80 per cent of premature deaths from cardiovascular diseases could be prevented through modifying health-related behaviour.
Obesity increases the risk of diabetes, cardiovascular disease, hypertension, some cancers and osteoarthritis.
Alcohol is an important contributor to hypertension as well as increasing the link to gastro-intestinal disease, a number of cancers, trauma, violence and falls.
The greatest risk to health is tobacco consumption which is linked to cancers, respiratory disease and cardiovascular disease. While smoking is reducing it continues to be a major cause of inequalities in health.
Obesity and alcohol consumption also contribute to inequalities and, unfortunately, show no reduction. That’s why it is so important that clinicians recognise their own role in prevention – to work in partnership with their patients, clients and service users to support them in having confidence in their own ability to change. Otherwise the NHS will face an unmanageable burden of chronic ill health and long term condition management.
If a publicly funded health service is to be sustainable – in line with the wishes of the vast majority of the British public – then we will have to start to really tackle behaviour related ill health as a part of the day to day work of clinical staff.
This is only one part of the story – local authorities have responsibility for the health of the population. Our contribution really needs to focus on secondary prevention – supporting behaviour change in our patients who already have risk factors and/or ill health.
The key fact that we need to impress on professional leaders and on front-line staff is that behaviour change interventions are effective and cost-effective. This is evidenced by NICE guidance on behaviour change and on alcohol, obesity and tobacco. One of the particular areas for potential gain is in long term condition management.
While the focus tends to be on those who are at high risk of repeated hospital admissions, behaviour change interventions can be highly effective for the vast majority of those with long-term conditions. In the earlier stages of chronic ill health lifestyle changes can make significant improvements in a patient’s prognosis.
Front line staff, while dealing with the patient’s immediate needs, also need to think in the medium and longer term to support the patient to prevent deterioration of their condition or the development of co-morbidities.
In order for front line staff to do this effectively their clinical leaders and managers need to give them support in terms of organisational commitment; building prevention in to clinical pathways; setting staff objectives to delivery prevention as part of their work, and ensuring that they have the training to support the development of the required competencies.
The intensity of interventions varies from brief and very brief interventions, which use some of the techniques of motivational interviewing, to multi-visit programmes which may use more advanced techniques such as those from Cognitive Behaviour Therapy.
All staff should have received the training to carry out very brief interventions and should know the indications for discussing health related behaviour with a patient. Those staff working with those at greater level of risk should be competent to carry out more intensive levels of behaviour change intervention.
I want to finish this reflection with the recognition that this is a real challenge to all of us who are clinicians. We are not trained to work in partnership with patients. We are trained to intervene, competently, effectively and safely. We are trained to take charge of the consultation, to be the experts. We are busy people and the realities and practicalities of people’s day to day lives are likely to slow us up. And in addition not everyone will thank us for advice.
The key to overcoming these challenges is through preventively-orientated training and professional development for clinical staff and clinical leaders. That is how we learn the effectiveness of behaviour change interventions – and also how we learn how to carry them out in a manner which is not simply effective but also acceptable to patients.
The secret is to listen to patients; to raise issues in a way which they perceive as relevant to the consultation, and to give them the chance to respond or chose not to respond; to seek and to find their own solutions and ways forward, and to accept or not to accept support in their proposed course of action. That partnership with patients is one of the most effective ways we can work, and also one of the most satisfying.
Those are some of the messages coming out of the CNO conference today and I’d like to thank all the Directors of Nursing and CNOs for their support and the expertise they have lent to us today towards effectively integrating prevention in all our clinical interventions.
You are right – we are not trained to work in EQUAL partnership with patients. So we need to go further – we need to understand WHY people drink, smoke etc – The residents were the only ones with the insight into what is happening in the communities in which they live. I must disagree with you that residents don’t always have the confidence or the emotional wellbeing to find their own solutions, especially when they suffer multiple disadvantage – see the work of LankellyChase for more on this.
And my experience is that many residents (patients is a passive term so I don’t use it) know full well what they are supposed to do and that some – especially in disadvantaged communities, either avoid us or tell us what we want to hear.
I have written a blog on the website above which explains how residents in the most disadvantaged communities feel judged by health care professionals and they are avoiding us. This may be one of the reasons why health inequalities is widening.
What does this mean for NHS England?
We need to understand how to work through communities rather than with individual residents – to help them to heal themselves – asset based approaches rather than deficit based
Through communities we need to understand the causes of the causes of unhealthy behaviours and then work in partnership with residents and other services to address them – like family breakdown, joblessness and homelessness. The Troubled Families programme is an example of this but we need to incorporate it into the nurses psyche
What are the approaches to public health?
1. Health protection – we do well
2. Health promotion – we do well
3. Addressing the social determinate of health – we need better partnership with residents and partner agencies, including the 3rd sector- but at least we understand the importance
4. Salutogenesis and asset based approaches – some of us don’t even know what these words mean – yet the Health Foundation is prepared to invest in a 10 year programme to facilitate its development.
We need a social model of health not just a clinical one – using complexity theory not mechanical theory – see Health Foundation, University of Exeter Health Complexity Unit and the work of Eve Mittleton Kelly at LSE
NHS Alliance is happy to help you to understand this further
Heather Henry, Queen’s Nurse